Chronic kidney disease (CKD) is a growing health concern and a major cause of morbidity and mortality worldwide (Neuen et al. 2017; Stevens, Viswanathan & Weiner 2010). Lack of awareness, failure to recognise early signs, and improper management of CKD contribute to CKD’s burden (Raymond et al. 2010). Patients with CKD and those with severe forms of CKD are at an increased risk of being exposed to drug-related problems, including adverse drug reactions and drug–drug interactions. The complex nature of the therapy, altered pharmacokinetics of the drugs and reduced renal function further dispose patients to drug-related problems (Stemer & Lemmens-Gruber 2011).

The renal Multidisciplinary Team (MDT) integrates the interventions of nephrologists, physicians, nurses, dieticians and pharmacists who provide care to patients with renal disorders (Chen et al. 2012). When properly implemented, this team meets the health demands of the patients when compared to individual patient–physician care (Clarke 2013). The role of a pharmacist in the renal MDT includes identifying, addressing and preventing drug-related problems, providing recommendations on drug selection and treatment plans, adjusting doses, preventing use of contraindicated drugs and enhancing patient adherence (Biradar et al. 2012; Splawski & Minger 2016). The inclusion of a pharmacist in the renal MDT further improves quality of life, reduces unnecessary drug use, and hospitalisation, and improves outcomes for anaemia, hypertension and diabetes mellitus for patients with CKD (Mekonnen et al. 2013; Odum & Whaley-Connell 2012). Pharmacists are also expected to play a role in renal drug cost management. These aspects contribute in cost saving for both patients and institutions and would be essential in developing countries struggling with resource limitations. In resource-limited countries with human resource challenges, pharmacists can also bridge the gap between physicians and patients by providing direct patient care (Shrestha, Shrestha & Palaian 2019). Renal therapy is costly and complex (Aviles-Gomez et al. 2006), and therefore pharmacists have the potential to contribute to the renal MDT (Al Raiisi et al. 2019). To further highlight the essential role of a pharmacist, Shulman et al. (2015) observed that one in six prescriptions requires an intervention from the clinical pharmacist.

Despite numerous studies demonstrating the positive outcomes of pharmacists practicing in wards (Chisholm-Burns et al. 2010; Chen et al. 2012; Jacobi 2016; Stemer & Lemmens-Gruber 2011), the role of pharmacists in the renal MDT remains limited especially in developing countries (Bronkhorst et al. 2014; Gray, Riddin & Jugathpal 2016; Mekonnen et al. 2013; Salgado et al. 2014). Factors such as conflicting departmental priorities, workload, resource-related constraints (space, finance and qualified personnel), system-related constraints, lack of clinical knowledge and discrepant attitudes of pharmacists, doctors and nurses are some of the barriers to pharmaceutical care (Acheampong & Anto 2015; Walker et al. 2014). It is against this background that the study aims to explore the role of pharmacists in renal care and proposes strategies based on their participation in the renal multidisciplinary health care team at a tertiary hospital in Limpopo province, South Africa.

A total of 17 health care professionals participated in this study, of whom 14 (82.4%) were females and three (17.6%) were males. Pharmacists were the majority with nine participants and the remaining eight (47.1%) participants were other healthcare professionals practicing in the renal unit. The renal MDT was comprised of a nephrologist, physician, two dieticians, a transplant coordinator, a unit manager, and two professional nurses. Participants’ age ranged between 29–57 the age group. All the participants had a working experience of over 5 years in practice.

Three themes emerged from the interviews. The main themes and subthemes are illustrated in Table 2. Respondents from the renal multidisciplinary team (MDT) are denoted by using the symbol Rtm (renal team), while P symbolises pharmacists.

Currently, the renal MDT in the Pietersburg hospital operates without pharmacists. The lack of their participation in renal the MDT is a historical problem pertaining to the classical role of the pharmacists. The role of pharmacists in the renal unit is currently limited to stock management and dispensing. This is in line with the results obtained from a recent study where majority of pharmacists were found to be more involved in the pharmaceutical product management such as ward stock inventory, compounding and dispensing (Katoue & Al-Taweel 2016; Sello & Dambisya 2014). While the integration of pharmacists in the wards to provide clinical services is common among First World countries such as the United States of America (USA) and and the United Kingdom (UK), it is still lacking in South Africa and other African countries (Bronkhorst et al. 2014; Gray et al. 2016; Mekonnen et al. 2013; Stemer & Lemmens-Gruber 2011).

The continuous absenteeism of pharmacists from the wards has created an environment where some of the participants in the renal unit believe that it is ‘fine working without’ pharmacists. This aspect may be related to the traditional practice of a pharmacy and lack of awareness and recognition of the role of pharmacists within the wards. Similarly, Krzyżaniak, Pawłowska and Bajorek (2018) found ignorance of pharmacists’ competencies and skills as one of the barriers. Therefore there is a need to raise awareness among healthcare professionals about the benefits of working with pharmacists in the wards (Alipour, Peiravian & Mehralian 2018). This should go along with the recognition of pharmacy services in the wards through collaborative efforts by all the stakeholders (health care professionals, healthcare institutions and their management, South African Pharmacy Council and the National and Provincial Department of Health). Employee recognition is an integral part of organisational management and is related to the basic needs of the employees (Brun & Dugas 2008). Hence pharmacists feel marginalised and discouraged to do ward rounds in the current set-up.

It is encouraging to note that although pharmacists are absent in the wards, the participants of the study believe that pharmacists can play a role in the management of renal patients. The inclusion of a pharmacist in the renal MDT can improve renal patients’ state of health and reduce drug-related problems (McNeely 2017; Salgado et al. 2014). Accordingly, participants indicated that pharmacists can review patients’ medication, work with prescribers during the prescribing stage, prevent the use of contraindicated drugs and to oversee dosage adjustments. Having a pharmacist undertaking these roles ensures effective use of medicines and improves the health outcome of patients and reduces the rate of readmissions (Shanika et al. 2018). Additionally, the involvement of a pharmacist in the early stages of drug therapy would serve as a source of patient customised pharmacological information to the team members. Given the current use of technology applications and abundance of information, pharmacists will play a major role in the dissemination and customisation of patient therapy.

Similar to a recent study (Katoue & Al-Taweel 2016), the participants in this study also highlighted patient education and counselling as one of the important roles to be played by pharmacists in the renal MDT. Patient education and counselling can reinforce patient adherence and understanding of medication. Therefore, there is a room to improve the renal patient care in the Pietersburg hospital by involving pharmacists in the provision of clinical services to the patients.

Results revealed a shortage of staff, pharmacists’ lack of clinical skills, negative attitude of pharmacists and other health care professionals and lack of recognition as the major barriers that limit the participation of pharmacists in the renal MDT. These findings are correlated because if the hospital does not have enough staffing, staff members will be overworked and have limited time to engage in professional development activities that will help them acquire more knowledge on therapeutics. The results in this study are compatible to those found by Ghazal and colleagues, as they reported lack of time, insufficient staffing and lack of motivation or vision of professional development to be the main barriers to the implementation of pharmaceutical care into pharmacies (Ghazal et al. 2014).

According to the South African Pharmacy Council (2018), pharmacists should be competent to participate as part of a healthcare team to ensure optimal pharmaceutical care. However, results from this study give the impression that undergraduate education may not be sufficient to ensure that pharmacists are competent to undertake this role. Similar results were also observed by Trinh et al. (2018) and Tegegn et al. (2018). James and Cole (2016) found that pharmacist interns in Sierra Leone were not prepared to practice in a MDT. There is a need to strengthen undergraduate pharmacy education in South Africa to be patient-orientated and empower pharmacists to practice in the MDT. Additionally, pharmacists should be life-long learners, striving towards continuous professional development and institutions of higher learning should develop relevant clinical short courses to support graduates of traditional product-orientated pharmacy curriculums. Even though clinical pharmacy practice in South Africa is not restricted to pharmacists with a postgraduate degree in clinical pharmacy, the lack of specialised clinical pharmacy postgraduates hampers the development and transition of pharmacy towards providing advanced direct patient clinical services (Sakeena, Bennett & McLachlan 2019; Trinh et al. 2018).

The discrepant attitude of some healthcare providers about the role of pharmacists being part of the MDT and patient care could be related to a lack of communication and/or coordination and lack of trust in the pharmacist’s abilities (Katoue et al. 2014). Interestingly, pharmacists believe that their roles are side-lined by doctors, but this could not be established from the doctors’ insights about having a pharmacist as part of the MDT in this study. This is in line with the results from a study conducted in Kuwait, on the role of pharmacists in parenteral nutrition therapy, as physicians were reported to assume total responsibility for the overall therapeutic decisions in collaborative teams (Katoue & Al-Taweel 2016).

Poor attitude of pharmacists to participate in MDTs may be explained by the lack of confidence and fear of new responsibilities among some pharmacists, which could have adversely affected their perception. In a recent study conducted by Rosenthal and colleagues, it was found that a culture exists among pharmacists to resist change, meaning pharmacists do not want to change from the traditional role of pharmacists to providing direct patient care (Rosenthal, Austin & Tsuyuki 2010).

The study was conducted at a tertiary hospital in Limpopo Province, and therefore may not apply to other hospitals offering renal care in South Africa and other countries. Additionally, the sample size was too small to generalise the findings from this study.

A potential opportunity exists for pharmacists to offer direct renal care services within the renal MDT. Given the complex nature of pharmacotherapy in CKD patients, there is a need for better integration of pharmacists within the MDT. As a means to identify and gain pharmacists to become part of the MDT it was important and critical to point out perceptions of the barriers, and to encourage the expansion of the pharmacist’s role in the MDT. While pharmaceutical care services are limited at Pietersburg hospital, strategies were recommended to successfully implement and encourage the participation of pharmacists in the renal MDT, with the consideration of standardising the practice of pharmacists in the wards, equipping both pharmacists and pharmacist assistants with the necessary skills and recognise pharmacist services in the wards. More importantly, pharmacists have the potential to be frontiers in the drive to recognise pharmacists as essential team players within the MDT by continuously providing useful clinical recommendations. Further research is needed to evaluate the possibility of implementation and outcome of the proposed strategies.